5 Physical Therapy Treatments You Might Want to Avoid

4 Comments

Do you reach for a bag of frozen peas to soothe a cranky knee after a long run? You might want to reconsider that choice, according to a new report from the American Physical Therapy Association (APTA).

As part of the American Board of Internal Medicine Foundation's "Choosing Wisely" initiative—a nationwide effort aimed at helping patients make more informed healthcare decisions—the APTA released a list of physical therapy treatments that can be ineffective, even dangerous, if prescribed improperly.

The roster includes some familiar therapies, including the aforementioned ice packs and using certain types of exercise machines.

"The Choosing Wisely initiative's purpose is to encourage conversations between providers and patients, which is key to success in physical therapy," says Neil Moss, partner and clinical director of Professional Physical Therapy in Bayside, New York.

Moss outlines the process that practitioners typically go through to determine the ideal physical therapy regimen for an older adult, beginning with a thorough evaluation of the patient's specific needs.

But a successful treatment program should be built on more than just a diagnosis. The goals and progress of the patient must be taken into account as well. "You can have two patients with the same diagnosis, but different physical findings, so the treatment plan must help with the patient's specific challenges," Moss says. For instance, if a 72-year-old woman who's just undergone a hip replacement is having trouble walking up and down the steps to her apartment, then her plan should involve exercises and activities that focus on making that task easier for her.

Treatment Plan Options

  • Modalities (e.g. ice, heat, electrical stimulation).
  • Therapeutic exercises to restore functional strength, range of motion, flexibility and endurance.
  • Neuromuscular re-education to restore balance, coordination, kinesthetic sense, motor coordination, posture and proprioception.
  • Directed therapeutic activities to restore functional performance.
  • Manual therapy (e.g. soft tissue mobilization, stretching) to restore mobility.

The ultimate goal of physical therapy, according to Trisha Brabender, a physical therapist who specializes in geriatrics, is to help older adults be as active as possible. She says, "Whatever the patient can do to maximize movement, then use that ability to improve functions," is key.

Treatments to Question

Given the ultimate aim of getting an older adult feeling (and moving) their best, the APTA reviewed countless treatments and came up with a list of interventions they feel might not be as beneficial as some therapists and patients think.

  1. Ice packs and heating pads: Ice packs, heating pads and other so-called "passive physical agents" may loosen tight muscles or assuage post-workout aches, but their effects don't last long, claim the APTA experts. Brabender says that while she may initially use these interventions along with manual therapy techniques to increase a patient's mobility, "the goal is always to move the patient away from passive physical agents and get them moving and pain free as quickly as possible."
  2. Whirlpool baths for wounds: Older adults, particularly those who are diabetic or who have circulation problems often develop wounds that are slow to heal. One of the traditional treatments for such wounds is immersing them in a whirlpool bath. However, the possibility of infection from a dirty tub, as well as jets and chemicals that may further disrupt the healing process are two huge disadvantages of this approach. "Never use whirlpool therapy to treat open wounds," the APTA experts state. Safer, healthier alternatives include spraying the wound with a cleansing liquid or rinsing it in a saltwater solution.
  3. Weak strength training programs: The right strength training program can work wonders for an older adult; increasing their balance and overall independence. Yet many physical therapists play it too safe when it comes to developing power programs for aging individuals. "Older adults are often prescribed low dose exercise and physical activity that are physiologically inadequate to increase gains in muscle strength," says the APTA. Such moderation is unnecessary, especially since, as Brabender points out, aging adults are often eager to improve their physical abilities. "Older adults are often much more compliant than younger people," she says. "They may have more time to devote to exercise if they are retired. They may have a new onset of arthritis or diabetes and feel very motivated to improve their health in order to enjoy grandkids, retirement, or just to age gracefully."
  4. Exercise machines after knee replacement: The idea behind the use of continuous passive motion machines (CPM) for post-surgical rehabilitation is to promote healing and mobility in joints that have recently been operated on. However, studies have shown that using CMP machines after knee replacement surgery may not be effective enough to justify the cost of the devices (patients often have to pay rental fees). A CPM machine also requires the user to remain in bed while performing the movements, thus limiting the length of time they can be up and walking around. "I have often felt that physical therapy over-utilizes machines and that we are sometimes complacent when designing exercise programs," says Brabender. Moss claims there are more effective alternatives to CPM machines that should be explored during rehabilitation discussions between therapists and patients.
  5. Bed rest to prevent blood clots: Deep vein thrombosis (DVT)—a blood clot that forms in deep veins like those found in the legs—poses a serious risk to older adults and people who've recently undergone surgery. If these clots break loose, they can travel to the lungs and become stuck, causing a potentially-fatal blockage called a pulmonary embolism. In order to cut down on the chances of renegade clot formation, patients are often prescribed blood thinners and advised to go on bed rest. However, research indicates that, for patients on blood thinners, pulmonary embolisms are no more common in patients who walk around than those who remain in bed. Bed rest also weakens the body overall and can cause clots to become bigger. As long as an individual can take clot-busting drugs (e.g. warfarin, Coumadin) and hasn't had a stroke or severe breathing issues, getting out of bed is probably their best bet, says the APTA.

These guidelines are not only supposed to give patients and providers pause when it comes to certain treatments, they are also meant to provide talking points to get an honest, open dialogue going. "During a rehabilitation program, it is critical to be an active, not passive, participant, but not only when discussing one's care, but also when it comes to activity," Moss says. "Patients must actively engage in physical therapy exercises to achieve optimal results with their recovery."

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4 Comments

Thanks for sharing these insights! Some of these seem like a no-brainer - like stopping whirlpool treatment for open wounds. Getting out of bed to prevent blood clots seems to have caught on within the medical community but perhaps not as fast within the physical therapy community. Getting out of bed to build strength post-joint replacement has caught on if my mother's experience is any indicator.

But what is posted are really just general guidelines. A professional therapist must do an evaluation and make a determination as to the best approach for his or her client. This often means balancing different concerns. For an otherwise healthy senior, pushing further with strength training may be a good idea. But what if the senior has a heart condition or other underlying condition that limits his or her ability to exert him or herself? That would have been my FIL. He would have done anything the therapist told him to do, if he could. But his body could only go so far. Therapists must keep this in mind...and those of us in the caregiver role need to do so as well.

Ice and heat for short term only....again, that's a balance that needs to be struck between the overall condition of the patient, the actual problem which needs the heat or ice, and the long term effectiveness of any physical therapy program. Yes, physical therapy can do a lot of good. It's not a cure-all. For instance, physical therapy did reduce and occassionally eliminate the pain in my arthritic knee. It also had a tendency to aggrevate my knee. I stopped after about six months of therapy. Meanwhile, there are only so many different solutions to knee pain. When all other options are considered, that bag of frozen peas is one of the least invasive, has very few if any medical side effects, and is relatively inexpensive in comparison with what else is out there. The take away from this item is that if heat and/or ice don't fix it, try PT. If PT doesn't fix it, you probably need to take it up a notch with the doctor. But all things considered, if heat/ice helps, fits your budget, and keeps you going...stick with the peas.
I'm going to be starting physical therapy soon, and I want to know what to expect. I trust that whoever I go to will know what not to have me do, but it's good to know. It's my knees that are the worst of it, the older I get, the worse they seem to get. Thanks for all the great information!
As an Orthopedic Technician I have seen the doctors orders for CPM or cold compression therapy be undermind by PT's down the line whose opinions may be valid but isn't this a discussion that should be between the doctor and the therapists . Not the therapist and the patient because the majority of patients getting CPM benefit from getting the active motion for many hours a day when not in therapy. The therapist opinion should not over ride the learned choices of treatment that a doctor feels would the most beneficial to their patients specific needs. And upon this order, the therapist job should be to encourage the patient to maximize their success using what the doctor feels is best. CPM's are a great benefit to flexion extension of any post op knee .